Health At Every Size: choice or coercion?

by Michelle

I wanted to address was something I read a while back, and have been sort of turning over in the back of my head ever since. [Via The Fat Girl.]

These are the fat acceptance zealots — using fat acceptance and ‘in your face’ fat imagery and messages in order to shock the world into accepting their fat as meaning they are valid, worthy and ultimately just as healthy as the next person.

“And really fat people are valid and worthy, but as healthy as the would be if their hearts weren’t beating much harder in order to accommodate an extra 100lbs?

“No — this simply cannot be.”

–Weighted Long Enough

This is the writing of a woman who was once passionately involved in fat acceptance. Presumably, she still believes in basic tenets like, you know, appearance-based discrimination is wrong. But she got to a point where she felt her fat was detrimental to her health.

Now, I wouldn’t presume to argue with a person about their own experience, except to say that I believe directly addressing comorbidities associated with fatness is probably more effective than addressing the fatness itself, given that there are precious few (read: NO) permanent, safe methods of fat reduction.

But still, a person is allowed to be the expert on their own experience. If she feels that fat was causing her health problems, who the hell am I to contradict her?

This is where I believe Health At Every Size connects with the fat movement. The fat movement, as I see it, is primarily about politics and human rights, and well it should be. These are the critical, the most important, factors determining our experiences as fat people. But because fat is inextricably bound up in matters of health, at least from the perspective of our oppressors, the HAES component is a critical tangent of our movement.

See, the thing is, people who are involved in fat acceptance don’t always seem to fully understand HAES, and this concerns me. It concerns me because it is a useful tool that many of us seem content to toss by the wayside. This woman is a prime example of not understanding the basic structure of the HAES philosophy…the first being that “Health At Every Size” means health at every size for the population, not necessarily the individual.

If you accept the theory of set-point, as many fat acceptance advocates do, then you realize that an individual body has a preferred level of adiposity, for which a handy (though imperfect) proxy is body weight. This not only means that maintaining a weight lower than set-point is not good for you, but also that maintaining a weight much higher than your body’s natural set-point range is also not good for you.

The thing is, despite what the BMI dorks seem to think, set-points, or body weights, or body compositions, naturally come in a wide variety. I like to think of this as one way our species protects itself against extinction by one poorly-timed famine, epidemic, or ice-age. If all our bodies operated identically, the human race could easily be wiped out in one fell swoop, because we’d all react in exactly the same way to dramatic environmental changes.

So there is variety in size. There is variety in nutrient requirements as well…not only for kcalories, and macronutrients like fat, protein, and carbohydrates, but also for vitamins and minerals. Now I know those RDAs and the popular multivitamin supplements and the Food Guide Pyramid and everything seem to suggest that we all have the same requirements, dependent on things like age and sex, but it’s not so. Those things are basically educated guesses on how we can catch most of the population, within its wide range of requirements, so that nutrient deficiencies are no longer widespread. There was a time when things like scurvy and rickets were near-epidemic, so the usefulness of these tools can’t be overstated. But they do not represent some magical, unequivocal number that super-smart scientists have determined to be the perfect amount of X nutrient for everyone in the whole world.

If you doubt this, I would like to turn your attention to the development of the DRIs, which are, basically, a more complex and comprehensive form of the RDAs. There were huge debates, for example, over the recommended intake of calcium. Calcium! A nutrient we all take for granted as being a set-in-stone, God-given prescription for strong teeth and bones! Well, the goddamn scientists argued so much over the RDA for calcium that they never came to consensus. So, yes, you read that right, there is no RDA for calcium at this time. Instead, they came up with a rough guesstimate (the AI), from which specific recommendations cannot be extrapolated.

Okay. Phew. Sorry for the Nutrition 101 lecture. I just wanted to illustrate my point that, if we can’t even come up with solid numbers for the entire population on something as basic as calcium, why do we assume that ideal weight can be so easily established?

It can’t. Just as it is not logistically feasible to thoroughly test and document the nutrient requirements of each individual across the entire population, it is logistically infeasible, and as yet IMPOSSIBLE (since we are nowhere near understanding all of the complex mechanisms that influence body weight), to determine every single person’s healthiest weight. For practitioners of the HAES model, the definition of ideal weight is this: the weight you maintain when you are eating nutritiously and getting adequate physical activity. Not some arbitrary, shame-inducing number on a goddamn table picked out by a bigot like Walter Willett. Sorry, but for all you BMI-lovers out there — them’s the breaks.

So, back to this woman. Is it possible that she maintained a weight that was above her own healthiest weight? YES. Does this mean that anyone else maintaining the same weight and body composition at similar height, age, and gender is also above their healthiest weight? NO.

Health at every size, as I have said approximately 7,386 times on this journal, does not mean that one individual can be healthy at every size. Cause you can’t. You’ve got a basic range, and the range may shift a bit during different stages of life, but you cannot run up and down the huge spectrum of possible body weights, like a pianist running his hands over the keys from lowest to highest, and expect to be perfectly healthy at each step.

It is perfectly possible that, by an individual definition, this woman was ‘overweight.’ The problem, though, with focusing on weight, even if it does prove to be causing health problems for a person (and this is rarely, if ever, proven), is that not only is there no way of predetermining an individual’s ideal weight, there ain’t much we can do about the weight anyway. Weight-loss treatments, from drugs to diets, are dismal failures. GI surgeries are risky and do not have a lot of long-term research to back them up (I won’t even mention the anal incontinence, or possible vitamin deficiences that can cause irreversible neurological damage. Oh wait, I just did. Sorry.) Even people trying to gain weight have some difficulty.

So it’s a bit of a bind, isn’t it? And even if someone buys fully into the political aspects of fat liberation (there, I said it, fat liberation), the health argument is just sitting there, waiting for them to have a bad day, or to get tired of being fat (which is a very real possibility in this culture), or to get sick in a way that a doctor would readily attribute to ‘obesity.’ Under these circumstances, it is very easy to see why even an ardent supporter of the politics of fat liberation might go and do a thing like have weight-loss surgery, or start a reducing diet, or take the newest FDA-approved fat-person extermination pill — I mean, ‘obesity treatment’ — and maybe start to side, just a little, with the attendant propaganda. Because cognitive dissonance is a bitch.

This is the where Health At Every Size becomes not only a useful tangent to fat liberation, but an essential component.

Listen: there is an alternative. We need not be extremists on either end of the spectrum of fattitude — one being the end that says “I am healthy no matter what” and the other being the end that says “I’ll take the Roux-en-Y with a side order of Meridia” — because, all-too-often in my experience, two extreme ends of any spectrum eventually meet in the same, frighteningly psychotic person. Like radio shock-jocks who go from an ultra-liberal upbringing to ultra-conservative vitriol in the brief time it takes to experience one adolescent disillusionment. Like the woman who writes about being “involved in the fat acceptance movement as a way to stay in an illusion that one can be extremely fat and healthy.”

Thing is, there are extremely fat and healthy people out there. That’s how the bell curve works. No, you cannot be healthy at every size. But we can. Here’s how:

You eat well. This is not a moralistic determination, nor is it the same from person to person. There are general suggestions that most people can safely follow, but the most important is to learn to listen to your gut. Try to resuscitate the cues that a lifetime of dieting and an eating-disordered culture have probably killed. If you can’t do it on your own — and many can’t; it’s hard — get someone to help you. Size-friendly therapists and dietitians exist, and many of them believe in an empowering philosophy of health promotion, which in English means: you get to make your own choices. You get to figure out what is best for you. Because even scientists can’t tell you how much goddamn calcium you need.

You move well. This is also hard to figure out, and I’m currently doing battle with it myself. Kell has some good ideas. Like we all have an appetite for food, I think we all have an appetite for movement. Think back to the way you might’ve played as a kid, the times you got restless from sitting still for too long. Try to remember a time when being sweaty and out of breath meant you were having an awesome time (if you’re lucky enough to have such memories.) Think back on those times, and try to come up with creative ways to have fun now. REAL fun, like the kind of fun you had when all you needed was a hot day and a sprinkler in the yard, or a jump-rope, or a piece of chalk and a stretch of concrete. When did adult movement become so boring and medicinal? Who says you need to have ‘proper footwear’ or a gym membership or all sorts of ugly spandex clothing in order to get a little hot and sweaty? If you’re into that kind of thing, cool; you have that many more options than the rest of us who hate all that shit. And if you hate it, take heart: so do I. But I won’t be disingenuous and pretend that physical activity has no bearing on our well-being. Neither will I deny that it’s more than possible to go out and find ourselves a bit of fun.

Third, you learn to deal with your body. Whatever size it’s at, whatever health conditions you might be facing, whatever colour it is, however big your butt is, or small your tits are, or anything. You take what God gave you, and you make the best of it. You do the treatment for any health problems by focusing directly on the problem itself, not by buying into the cultural fantasy that, if you lose weight, you’ll magically lose any physical and/or mental illnesses along with it.

By doing this, your body is going to change in whatever way is best for it to change. You don’t get to control that. It might mean gaining weight, in the form of fat or muscle, and feeling self-conscious. But we have tools to deal with that, because that is what this whole movement is about: creating a society where people of all sizes can feel reasonably welcome.

It might mean losing weight, and you might feel guilty, like you’re betraying your fat liberation buddies. But you’re not betraying anyone. A real betrayal would be to go and swallow shit like “I wanted to believe I could be as healthy as a person whose weight didn’t literally drag them down. This was my greatest lie – a lie that allowed me to get more and more fat, until I’ve now reach the point of do or die.” Betrayal would be to believe that, in order to be healthy, you must first focus on changing your body to a socially-enforced ideal…in order, presumably, to become ‘deserving’ of proper health- and self-care. Betrayal would also be to totally deny the fact that eating and moving well will have a positive impact on your health, and that, if you want to, you deserve those things as much as anyone else.

Most likely, no matter how your weight changes, your basic health indicators are going to improve. Your blood pressure is probably going to improve, as well as your blood cholesterol, and your ability to use insulin and regulate your own blood sugar. These are much more accurate proxies for health than body size could ever be. And if things get worse, it’s a sure sign that something else is going on and you need to see a doctor. But for most people, you can bank on the fact that eating and moving well and treating your body with respect is only going to make things better, whether or not you get bigger or smaller in the process.

Listen: as surely as we are oppressed by systematic external discrimination, we collude in our own oppression by not demanding the care we deserve from health professionals, and by not caring for ourselves in the way we deserve. And don’t you believe for a MINUTE that you have to submit to ‘their’ idea of health and self-care, or the health meritocracy. First and foremost, all of this is a choice. It is optional. But in order for that choice to even exist, we have to have access to good information, and we have to really believe that we deserve to be cared for. I have a sneaking suspicion that an internalized sense of inferiority drives a lot of our rebellion against ideas of self-care and health at every size. And I totally understand. I get panicky, too, when I entertain ideas of ‘making healthy choices’ and what-not because, more often than not in our deranged, pathological society, ‘making healthy choices’ is code for ‘submitting to coercion.’ I know. I know. But we can’t let the difficulty of the fight let us stop fighting it.

There are size-friendly health professionals out there. There are dietitians and therapists and doctors in a number of specialties who are on our side. We definitely need more of them, and that’s another thing we’re working on, but we should be taking advantage of the ones we’ve got. (Check out Stef’s Fat Friendly Health Professionals page.) We also need better resources for general information on health and nutrition — in print, on the internet, on TV — stuff that comes from a size-positive perspective (hell, even a size-neutral perspective would be an improvement over what we’ve got now.)

Pattie pointed out that a lot of the HAES terminology is being co-opted by forces that are anything but size-friendly. This scares me, and I think one of the reasons they’ve been able to do this is that HAES has not yet come into its own. One of the things we’ve got to fight for is to make HAES work, and work in the way we want it to. We can’t let it revert into yet another health-fascist approach that’ll only find creative new ways to blame and marginalize people in the name of health.

Pattie also talked about how the personal is political.” With the way things currently are, what could be more political than for people to stand up, demand quality health-care, and to make truly free and informed choices about their health, regardless of what size they are? In a true HAES framework, this would never result in dividing us into ‘good people’ and ‘bad people.’ It would simply give people of all sizes the information and support they need to make real choices — something we don’t currently have, since most of our resources are hopelessly tainted by their association with “Brand Thin” — and its mandate would be to then respect those choices, whether they might be classified by the majority as ‘healthy’ or not.

If we’re fighting a war here (I’ll indulge in some militaristic language, since everyone else seems so eager to compare fat people to terrorists and to declare ‘war on obesity’), we need our troops to be as strong as possible. And that doesn’t mean conforming to some arbitrarily defined, absolutist notion of what ‘health’ is. To me, health is a matter of making autonomous choices, and having the resources necessary to inform those choices. Though we may all disagree on which behaviours are healthy or not, I think we can all agree that losing once-fervent supporters to the health meritocracy does not strengthen our numbers. Having an alternative that emphasizes good information, respectful practitioners, and a culture of individual sovereignty will.